Guideline for Rotator cuff rehabilitation

There are many school of thoughts for RC rehabilitation, here we try to make you easy understanding how to approach . While assessing the rotator cuff in person .

when patient come to us after rotator cuff repair surgery we need to fully understand his daily activities affecting their ability to their normal life. Here there are few keys that need to be consider…….

Key consideration factors in Rotator Cuff Rehab :

• age of the patient,
• activity level,
• injury to affected shoulder,
• response to previous treatment,
• imaging and what were the findings,
• past medical history,
• joint status (hypermobile or hypomobile),
• what they think is going on in their shoulder,
• most importantly is the ultimate goal of the client.

 

Plan for treatment……..

what do we do for people presenting some form of shoulder pain? There are many different answers but for the purpose of this, we will keep it simple that will help restore
pain free ROM, strength, and slowly return them back to their functional level.

Control on the shoulder pain :

We want to get the shoulder joint moving through self-ROM activities. We prefered patient to go for foam roll their thoracic spine and Latismus dorsi muscles to achieve overhead shoulder mobility. We will work on external rotation ROM at 45 degrees and 90 degrees of abduction.

Following this exercise we prefer to work on shoulder flexion AAROM in supine position, once gradually ROM restore we’d prefer kinetic chain activation exercise.

For strengthening,we like to begin with isometric activities to help with pain control.

 

When to start  higher level strengthening programme:

Once you achieve all criteria for advanced training we would like to start strengthening activities, we add isotonic strength training with  theraband  : full can, sidelying external rotation, prone horizontal abduction, prone extension and prone full can. There are Many studies have shown the EMG activity of the rotator cuff and scapula stabilizers to be relatively high with most of these activities.

There are  evidance, we like to add program in our routine protocol but will change the weights, sets and reps depending on Patient tolerance during exercise.

We rarely have patients perform 3 sets of 10 repetitions so the goal of the exercise needs to be fully understood in order to prescribe it correctly.

Advanced strengthening :

Once an adequate base of strength is achieved , we will add another level of strengthening programme depending upon patient’s requirement. We also focus on proprioceptive exercise once adequate strength achieved.

For athlete , Plyometric strength training is incorporated to allow the athlete to produce a force and power in his sports activities. which will hopefully help them in their return to their sport. This may include chest press, overhead throws, and rotational throws etc…

Pull ups, push-ups, bench pressing and overhead pressing are also added to make sure the athlete is strong in multiple planes to performing his sports.

Finally,The key is knowing the ultimate goal of the athlete .there are many factors that need to be considered when returning a patient back to their highest functional level when they have a  cuff injury.

This post was my attempt at outlining a very general guideline for an athlete or non athletic poplution with a rotator cuff issue and what my thought process may be.

Remember, listen to their issues…they may just tell you what program is best for them!

Any question!!!!!!!

 

image courtesy: I.pinimg.com

Scapula stabilisation

Thoughts on Scapula exercise

Scapula exercises are very common and usually a needed to any shoulder rehabilitation or corrective exercise program.    No program is right for everyone!  Here are of scapular exercises that we thought would good to discuss.

 

1) Pinch Your Shoulder Blades Together :

Pinch your shoulder blades , Squeeze your scaps together.  Retract your shoulders back.  These are common coaching cues given during scapular exercises.  The goal of these concepts is to get into better posture and set your scapula  in correct postion ,ultimately resulting in  better movement patterns along with better posture  when performing exercises.

The classic example is Upper Body Cross Syndrome of forward head, rounded shoulders.

scapulohumeral rhythm requires a sequence of shoulder and scapular movement simultaneously.  Pinching your shoulder blades together is essentially contracting your middle trapezius to fully retract your scapula and then move your arm.  While this is not nearly as bad on shoulder mechanics as lifting your arm . it does not have good advantage to lift your arm in a fully retracted position. While fully retract the scapula  which is essentially performing and isometric trapezius contraction, you are likely to limit the normal protraction and upward rotation movement  that occurs  during arm elevation and movement.

If the milestone  of this to give cue for  improve posture and improve mechanics while exercising the arm, maybe a better cue would be to instruct thoracic extension.

Think about , you can still have a very kyphotic and rounded thoracic spine and retract your scapula, it’s. Very difficult to perform , but the goal is to really get your thoracic spine extended.

2) Mobility and Strength to Improve Scapular Symmetry.

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Introduction to core subsystem

Muscles don’t work alone to create movement. They work together in synergies to create coordinated movements. Here we’ll identify the four muscle subsystems, discover how these synergies work together, and how to select exercises for developing optimal performance.

Introduction :

The purpose of this article is to provide a brief overview and definition of the four subsystems within the human body , how they contribute to human movement system .
Muscle does not work in isolation. This simplifies movement by allowing muscles and joints to operate as a cohesive unit. For instance, during the simple act of shoulder extension, the latissimus dorsi, teres major, and posterior deltoid all work together as a unit to perform the movement pattern.

Local vs. Global Musculature:

Looking at the muscular system more closely, systems that enable our bodies to distribute forces efficiently. These systems include the local muscular system, known as the stabilization system, and the global muscular system, which referred to as the movement system.

. The local muscular system muscles provide stability and support during joint motion. Where as they are usually located in close to the joint which makes them ideal for increasing joint stiffness and stability, such as the transverse abdominis, multifidus, and pelvic floor.

On the other hand, the global muscular system is responsible for movement of the trunk and extremities, and primarily consists of large superficial musculature, such as the rectus abdominis, latissimus dorsi, and external obliques.

Subsystems:

The human body consists of four common muscle synergies:

• Lateral subsystem,
• Deep longitudinal subsystem,
• Posterior oblique subsystem,
• Anterior oblique subsystem.

These subsystems allow for an easier description and review of functional anatomy. The human body simultaneously utilizes all four of these subsystems during activity of daily routine.

Figure 1

The lateral subsystem (Figure 1) is comprised of the gluteus medius, tensor fascia latae, adductor complex, and contralateral (opposite) quadratus lumborum. The lateral subsystem is implicated in frontal plane stability and is responsible for pelvo-femoral stability during single-leg movements such as in gait, lunges, or stair climbing. The ipsilateral (same side) gluteus medius, tensor fascia latae, and adductors combine with the contralateral quadratus lumborum to control the pelvis and femur in the frontal plane.

Proactive physiotherapy india

Figure 2

Deep Longitudinal Subsystem :

The deep longitudinal subsystem (Figure 2) is comprised of the erector spinae, thoracolumbar fascia, sacrotuberous ligament, and bicep femoris. The deep longitudinal subsystem helps to stabilize the body . More accurately , it provides force transmission longitudinally from the foot and ankle to the trunk and vice versa. The dominant role of the deep longitudinal subsystem is to control ground reaction forces during gait motions .

Core subsystem

Figure 3

Posterior Oblique Subsystem:

The posterior oblique subsystem (Figure 3) is comprised of the gluteus maximus, latissimus dorsi, and thoracolumbar fascia. The posterior oblique subsystem works synergistically with the deep longitudinal subsystem which distributing transverse plane forces . The gluteus maximus and latissimus dorsi attach to the thoracolumbar fascia, which connects to the sacrum. The fiber arrangements of these muscles run perpendicular to the sacroiliac joint (SIJ). Thus the contralateral gluteus maximus and latissimus dorsi contract they create a stabilizing force for the SIJ.

Core subsystem

Figure 4

 

Anterior Oblique Subsystem:

The anterior oblique subsystem (Figure 4) is comprised of the internal oblique, external oblique, adductor complex, and hip external rotators. Likewise, the posterior oblique subsystem this system also functions in a transverse plane orientation, only from the anterior portion of the body. When we walk our pelvis must rotate in the transverse plane in order to create a swinging motion for the legs. This rotation comes in part from the posterior oblique subsystem posteriorly and the anterior oblique subsystem anteriorly.

 

Stay tune with us for next part : integrated exercise for core subsystem.

 

References :

1) Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989;230:1-54.

2) Clark MA. Lucett SC. Sutton, BG. NASM Essentials of Corrective Exercise Training 1st Edition Revised. Burlington, MA: Jones and Bartlett Learning; 2014.

3) image courtesy: Brian Sutton MS, MA, NASM-CPT, PES, CES ,  drstaceynaito.file.wordpress.com

Cervicogenic Headache : What’s the Evidencebase treatment?

How many of your patients with neck pain suffer from headaches as well, or vice-versa? Cervicogenic headaches are characterized by unilateral headache radiating from the posterior to anterior head, unilateral upper cervical pain and facet “locking,” which is often aggravated by sustained neck positions. 

For cervicogenic headache patients, modalities such as TENS, cryotherapy, or low-level laser therapy can be helpful. Spinal manipulative therapy has been shown effective for cervicogenic headache patients in several studies. Other manual therapies such as instrument-assisted soft tissue mobilization and kinesiological taping can be helpful adjuncts.

Therapeutic exercise including muscle stretching and specific strengthening exercises can help address muscle imbalances seen in cervicogenic headaches. Several studies have shown that cervical strengthening exercises with  elastic resistance can help reduce headache and neck pain symptom.

In summary, management of cervicogenic headaches begins with an accurate diagnosis.  A multi-modal approach including Thera-Band exercises, modalities and manual therapies can help to reduce  symptoms of cervicogenic  headache.

Cervicogenic headaches: An evidence-led approach to clinical management.  

  2011 Int J Sports Phys Ther. 6(3):254-266.